Search

Endurance runners exhibit an elevated prevalence of low bone mass and characteristics consistent with undernourishment.This quasi-experimental, pretest-posttest design study evaluated the efficacy of a 4-week nutrition education curriculum to optimize nutrition knowledge, self-efficacy, and the intake of nutrient-rich carbohydrate foods.Forty-eight adolescent endurance runners, age 15.7 ± 1.2 y, from two high schools in Southern California were recruited to complete four, weekly lessons addressing the quantity, quality, and timing of carbohydrate intake. Differences in pre- compared to post-intervention nutrition knowledge and self-efficacy to consume nutrient-rich carbohydrate foods were evaluated using paired samplesThe percent of nutrition knowledge questions answered correctly increased after Lessons 1 and 2 (59.0% ± 20.0% pre- vs. 81.9% ± 22.8% post-Lesson 1; 44.7% ± 13.7% pre- vs. 74.5% ± 17.4% post-Lesson 2

OBJECTIVE To evaluate the agreement between a 61-item Nutrition Screening Survey (NSS) and 127-item validated Food Frequency Questionnaire (FFQ). PARTICIPANTS Forty-seven college students (male, n = 29; female, n = 18), age 21.7 ± 0.4 years, BMI of 23.5 ± 0.4 kg/m2. METHODS Participants completed the NSS, Block FFQ, and anthropometric measurements. Pearson's correlation, paired sample t test, and Bland-Altman plot evaluated agreement between the assessments. RESULTS Moderate to strong associations between assessments (0.61-0.89, p

Energy status plays a key role in the health of athletes and exercising individuals. Energy deficiency/low energy availability (EA), referring to a state in which insufficient energy intake and/or excessive exercise energy expenditure has resulted in compensatory metabolic adaptations to conserve fuel, can affect numerous physiological systems in women and men. The Female Athlete Triad, Male Athlete Triad, and Relative Energy Deficiency in Sport (RED-S) models conceptualize the effects of energy deficiency in athletes, and each model has strengths and limitations. For instance, the Female Athlete Triad model depicts relationships between low EA, reproductive, and bone health, underpinning decades of experimental evidence, but may be perceived as limited in scope, while the more recent RED-S model proposes a wider range of potential health effects of low EA, though many model components require more robust scientific justification. This critical review summarizes current evidence regarding the effects of energy deficiency on athlete health by addressing the quality of the underlying science, the strengths and limitations of each model, and highlighting areas where future research is needed to advance the field. With the health and wellness of athletes and exercising individuals as the overarching priority, we conclude with specific steps that will help focus future research on the Female and Male Athlete Triad and RED-S, and encourage all researchers, clinicians, and practitioners to collaborate to support the common goal of promoting the highest quality science and evidence-based medicine in pursuit of the advancement of athletes’ health, well-being, and performance.

BACKGROUND Bone stress injury (BSI) in youth runners is clinically important during times of skeletal growth and is not well studied. OBJECTIVE To evaluate the prevalence, anatomical distribution, and factors associated with running-related BSI in boy and girl middle school runners. DESIGN Retrospective cross-sectional study. SETTING Online survey distributed to middle school runners. METHODS Survey evaluated BSI history, age, grade, height, weight, eating behaviors, menstrual function, exercise training, and other health characteristics. MAIN OUTCOME MEASUREMENTS Prevalence and characteristics associated with history of BSI, stratified by cortical-rich (eg, tibia) and trabecular-rich (pelvis and femoral neck) locations. PARTICIPANTS 2107 runners (n = 1250 boys, n = 857 girls), age 13.2 ± 0.9 years. RESULTS One hundred five (4.7%) runners reported a history of 132 BSIs, with higher prevalence in girls than boys (6.7% vs 3.8%, p = .004). The most common location was the tibia (n = 51). Most trabecular-rich BSIs (n = 16, 94% total) were sustained by girls (pelvis: n = 6; femoral neck: n = 6; sacrum: n = 4). In girls, consuming

ObjectivesWe evaluated the effect of a nutrition education intervention on bone stress injury (BSI) incidence among female distance runners at two NCAA Division I institutions.MethodsHistorical BSI rates were measured retrospectively (2010–2013); runners were then followed prospectively in pilot (2013–2016) and intervention (2016–2020) phases. The primary aim was to compare BSI rates in the historical and intervention phases. Pilot phase data are included only for descriptive purposes. The intervention comprised team nutrition presentations focused on optimising energy availability plus individualised nutrition sessions for runners with elevated Female Athlete Triad risk. Annual BSI rates were calculated using a generalised estimating equation Poisson regression model adjusted for age and institution. Post hoc analyses were stratified by institution and BSI type (trabecular-rich or cortical-rich).ResultsThe historical phase included 56 runners and 90.2 person-years; the intervention phase included 78 runners and 137.3 person-years. Overall BSI rates were not reduced from the historical (0.52 events per person-year) to the intervention (0.43 events per person-year) phase. Post hoc analyses demonstrated trabecular-rich BSI rates dropped significantly from 0.18 to 0.10 events per person-year from the historical to intervention phase (p=0.047). There was a significant interaction between phase and institution (p=0.009). At Institution 1, the overall BSI rate dropped from 0.63 to 0.27 events per person-year from the historical to intervention phase (p=0.041), whereas no decline was observed at Institution 2.ConclusionOur findings suggest that a nutrition intervention emphasising energy availability may preferentially impact trabecular-rich BSI and depend on team environment, culture and resources.

Understanding the prevalence and factors associated with running-related injuries in middle school runners may guide injury prevention.To determine the prevalence of running-related injuries and describe factors related to a history of injury.Retrospective cross-sectional study.Survey distributed online to middle school runners.Participants completed a web-based survey regarding prior running-related injuries, training, sleep, diet, and sport participation.Prevalence and characteristics differentiating girls and boys with and without running-related injury history adjusted for age.Youth runners (total: 2113, average age, 13.2 years; boys: n = 1255, girls: n = 858).Running-related injuries were more prevalent in girls (56% vs. 50%, p = .01). Ankle sprain was the most common injury (girls: 22.5%, boys: 21.6%), followed by patellofemoral pain (20.4% vs. 7.8%) and shin splints (13.6% vs. 5.9%); both were more prevalent in girls (p .001). Boys more frequently reported plantar fasciitis (5.6% vs. 3.3%, p = .01), iliotibial band syndrome (4.1% vs. 1.4%, p = .001) and Osgood-Schlatter disease (3.8% vs. 1.2%, p = .001). Runners with history of running-related injuries were older, ran greater average weekly mileage, ran faster, had fewer average hours of sleep on weekends, skipped more meals, missed breakfast, and consumed less milk (all p .05). Girls with history of running-related injuries reported higher dietary restraint scores, later age of menarche, more menstrual cycle disturbances, and higher likelihood of following vegetarian diets and an eating disorder diagnosis (all p .05). Runners with no history of running-related injuries were more likely to have participated in ≥2 years of soccer or basketball (p .001).Most middle school runners reported a history of running-related injuries and certain injuries differing by gender. Modifiable factors with the greatest association with running-related injuries included training volume, dietary restraint, skipping meals, and less sleep. Sport sampling, including participation in ball sports, may reduce running-related injury risk in this population.

The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.

Context Sport specialization may contribute to sport injury and menstrual dysfunction in female high school distance runners. Despite the recent growth in sport specialization, including among high school–aged runners, the association of sport specialization with bone mineral density (BMD) remains poorly described. Objective To evaluate whether sport specialization was associated with BMD in female high school distance runners. Design Cross-sectional study. Setting Six high schools. Patients or Other Participants Sixty-four female runners (age = 15.6 ± 1.4 years) who competed in cross-country or track distance events and were not currently on birth control medication. Main Outcome Measure(s) Each runner completed a survey on menstrual history and sport participation. Height and weight were measured, and dual-energy x-ray absorptiometry was used to measure whole-body, spine, and hip BMD. Each runner was assigned a sport specialization status: low (participation in ≥1 nonrunning sport and distance-running sport(s) for ≤8 mo/y); moderate (participation in both distance-running sport(s) ≥9 mo/y and ≥1 nonrunning sport(s) or limited to distance-running sport(s) for ≤8 mo/y); or high (participation only in distance-running sport(s) for ≥9 mo/y). Multivariable logistic regression was performed to determine the adjusted odds ratio and 95% confidence interval for sport specialization to BMD values, adjusting for body mass index and gynecological age. Results Overall, 21.9%, 37.5%, and 40.6% of participants were high, moderate, or low sport specializers, respectively. Low BMD (spine or whole-body BMD z score < −1.0 [standardized by age and sex normative values]) was present in 23 (35.9%) runners. Compared with low sport specializers, high sport specializers were 5 times more likely (adjusted odds ratio = 5.42, 95% confidence interval = 1.3, 23.3; P = .02) to have low BMD. Conclusions A high level of sport specialization in high school female distance runners may be associated with a heightened risk for low BMD. Further investigation of this association is warranted due to the health concerns about low BMD in adolescent female runners.

Despite the worldwide popularity of running as a sport for children, relatively little is known about its impact on injury and illness. Available studies have focused on adolescent athletes, but these findings may not be applicable to preadolescent and pubescent athletes. To date, there are no evidence or consensus-based guidelines identifying risk factors for injury and illness in youth runners, and current recommendations regarding suitable running distances for youth runners at different ages are opinion based. The International Committee Consensus Work Group convened to evaluate the current science, identify knowledge gaps, categorise risk factors for injury/illness and provide recommendations regarding training, nutrition and participation for youth runners.

Objective To evaluate dietary supplement information needs among collegiate athletes. Methods Three hundred seven (n = 154 male; n = 153 female) student athletes participating in a National Collegiate Athletic Association Division I team completed a dietary supplement survey. Qualitative coding addressed open-ended responses, and chi-square test of independence explored differences among athlete subgroups. Results Five themes representing athletes’ information needs included quality/composition (53.5%; n = 77), general information (31.9%; n = 46), nutrition information (30.6%; n = 44), performance (18.8%; n = 27), and body composition (13.2%; n = 19). Athletes with “no” or “minimal” (n = 63), vs “moderate” or “strong” (n = 195), perceived knowledge of supplement safety were more likely to list a question about supplement quality or composition (34.9% [n = 22/63] vs 21.5% [n= 42/195]; P = .03; chi-square = 4.6). Conclusions and Implications Further research is needed to corroborate findings to inform educational efforts and promote safe and effective use of dietary supplements by student athletes.

Supplements may expose athletes to dangerous ingredients, banned substances, toxins or contaminants; however, few investigations assess use among collegiate athletes in the U.S. OBJECTIVE: This cross-sectional study evaluated habitual dietary supplement intake, defined use ≥2 days/week over the past year, in NCAA Division I athletes. METHODS: Male and female members of a NCAA Division I team, at two universities in southern California completed a 13-item survey. Among 705 eligible participants, 596 submitted surveys (84.5% response rate), 557 surveys included complete data. Chi-square (χ(2)) analyses evaluated differences among athletes based on sex, weight status, year in college, and sport-type. Independent t-test or ANOVA evaluated mean differences for continuous variables. RESULTS: A total of 45.2% athletes (n= 252) reported taking supplements (≥2 days/week over the past year). Vitamin/minerals (25.5%, n= 142), protein/amino acids (24.6%, n= 137) were used most frequently. Male, vs. female athletes, took more supplements overall (1.2 ± 0.1 vs. 0.8 ± 0.1, p = 0.004) and indicated higher use of protein/amino acid products (34.2% vs. 13.5%, p

OBJECTIVE: To describe: 1) parental perceptions of team snacks; 2) factors that motivate snack choice; and 3) perceptions of healthy snacking guidelines in youth sports. METHODS: Six in-depth group interviews were conducted among parents (n=22) of children ages 4–12 in two Los Angeles County baseball little leagues. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis. RESULTS: Parents perceived fruit as the “ideal snack;” this ideal was balanced with competing priorities, including children’s preferences, cost, time, and social norms around snacks as rewards and team bonding. While parents were supportive of promoting healthy snacks, they believed snacking guidelines should not be mandated. CONCLUSIONS AND IMPLICATIONS: Using team leaders as role models and developing messages that align with parents’ motivations when choosing snacks could promote healthier snacking in youth sports. Future studies to explore drivers of snacking with a broader sample and how to effectively promote healthy snacks are warranted.

This prospective study evaluated the 3-year change in menstrual function and bone mass among 40 female adolescent endurance runners (age 15.9 ± 1.0 years) according to baseline disordered eating status. Three years after initial data collection, runners underwent follow-up measures including the Eating Disorder Examination Questionnaire and a survey evaluating menstrual function, running training, injury history, and prior sports participation. Dual-energy X-ray absorptiometry was used to measure bone mineral density and body composition. Runners with a weight concern, shape concern, or global score ≥4.0 or reporting >1 pathologic behavior in the past 28 days were classified with disordered eating. Compared with runners with normal Eating Disorder Examination Questionnaire scores at baseline, runners with disordered eating at baseline reported fewer menstrual cycles/year (6.4 ± 4.5 vs. 10.5 ± 2.8, p = .005), more years of amenorrhea (1.6 ± 1.4 vs. 0.3 ± 0.5, p = .03), and a higher proportion of menstrual irregularity (75.0% vs. 31.3%, p = .02) and failed to increase lumbar spine or total hip bone mineral density at the 3-year follow-up. In a multivariate model including body mass index and menstrual cycles in the past year at baseline, baseline shape concern score (B = −0.57, p value = .001) was inversely related to the annual number of menstrual cycles between assessments. Weight concern score (B = −0.40, p value = .005) was inversely associated with lumbar spine bone mineral density Z-score change between assessments according to a multivariate model adjusting for age and body mass index. These finding support associations between disordered eating at baseline and future menstrual irregularities or reduced accrual of lumbar spine bone mass in female adolescent endurance runners.

The Male Athlete Triad is a syndrome of 3 interrelated conditions most common in adolescent and young adult male endurance and weight-class athletes and includes the clinically relevant outcomes of (1) energy deficiency/low energy availability (EA) with or without disordered eating/eating disorders, (2) functional hypothalamic hypogonadism, and (3) osteoporosis or low bone mineral density with or without bone stress injury (BSI). The causal role of low EA in the modulation of reproductive function and skeletal health in the male athlete reinforces the notion that skeletal health and reproductive outcomes are the primary clinical concerns. At present, the specific intermediate subclinical outcomes are less clearly defined in male athletes than those in female athletes and are represented as subtle alterations in the hypothalamic-pituitary-gonadal axis and increased risk for BSI. The degree of energy deficiency/low EA associated with such alterations remains unclear. However, available data suggest a more severe energy deficiency/low EA state is needed to affect reproductive and skeletal health in the Male Athlete Triad than in the Female Athlete Triad. Additional research is needed to further clarify and quantify this association. The Female and Male Athlete Triad Coalition Consensus Statements include evidence statements developed after a roundtable of experts held in conjunction with the American College of Sports Medicine 64th Annual Meeting in Denver, Colorado, in 2017 and are in 2 parts-Part I: Definition and Scientific Basis and Part 2: The Male Athlete Triad: Diagnosis, Treatment, and Return-to-Play. In this first article, we discuss the scientific evidence to support the Male Athlete Triad model.

Barrack, MT, Fredericson, M, Dizon, F, Tenforde, AS, Kim, BY, Kraus, E, Kussman, A, Singh, S, and Nattiv, A. Dietary supplement use according to sex and Triad risk factors in collegiate endurance runners. J Strength Cond Res 35(2): 404-410, 2021-This cross-sectional study evaluated the prevalence in the use of dietary supplements among elite collegiate runners among 2 NCAA Division I cross-country teams. At the start of each season from 2015 to 2017, male and female endurance runners were recruited to complete baseline study measures; the final sample included 135 (male n = 65, female n = 70) runners. Runners completed a health survey, web-based nutrition survey, and Triad risk assessment. The prevalence of dietary supplement use and Triad risk factors, including disordered eating, low bone mass, amenorrhea (in women), low body mass index, and stress fracture history, was assessed. A total of 78.5% (n = 106) runners reported taking 1 or more supplements on ≥4 days per week over the past month, 48% (n = 65) reported use of ≥3 supplements. Products used with highest frequency included multivitamin/minerals 46.7% (n = 63), iron 46.7% (n = 63), vitamin D 34.1% (n = 46), and calcium 33.3% (n = 45). More women, compared with men, used iron (61.4 vs. 30.8%, p < 0.001) and calcium (41.4 vs. 24.6%, p = 0.04); men exhibited higher use of amino acids and beta-alanine (6.2 vs. 0%, p = 0.04). Runners with bone stress injury (BSI) history, vs. no previous BSI, reported more frequent use of ≥3 supplements (61.5 vs. 32.8%, p = 0.001), vitamin D (49.2 vs. 19.4%, p < 0.001), and calcium (47.7 vs. 19.4%, p = 0.001). Low bone mineral density was also associated with higher use of vitamin D and calcium. Most runners reported regular use of 1 or more supplements, with patterns of use varying based on sex, history of BSI, and bone mass.

This cross-sectional study investigated associations between cognitive dietary restraint (CDR), energy, macronutrient and food group intake, menstrual function, and bone density in female adolescent endurance runners. Participants were forty female adolescent endurance runners. The independent variable was CDR, as assessed by the Three Factor Eating Questionnaire (TFEQ). Runners with CDR subscale scores ≥11 were classified with elevated CDR. The main outcomes measured were dietary intake measured by 24-hour recall for 7 days, menstrual history, and bone mineral density (BMD). Twelve of 40 participants (30.0%) met criteria for elevated CDR. Compared to runners with normal CDR, runners with elevated CDR scores reported consuming lower energy (kcal/kg/day) (37.5 ± 8.6 vs. 44.0 ± 9.6, p = 0.052), lower carbohydrate (g/kg/day) (5.3 ± 1.3 vs. 6.3 ± 1.3, p = 0.042), more fiber (g/day) (24.9 ± 6.7 vs. 20.0 ± 5.3, p = 0.018), more servings of fruit (3.3 ± 1.4 vs. 1.9 ± 1.2, p = 0.003), more servings of vegetables (2.7 ± 1.4 vs. 1.7 ± 0.7, p = 0.004), and fewer servings of grain (7.6 ± 2.4 vs. 9.8 ± 2.4, p = 0.009) per day. Runners with elevated CDR exhibited significantly lower lumbar spine BMD Z-scores (adjusting for BMI) (−0.78 ± 0.19 vs. −0.22 ± 0.12, p = 0.016) than runners with normal CDR. Menstrual history did not significantly differ based on CDR status. Elevated CDR may increase risk of dietary patterns associated with consuming inadequate levels of energy, key nutrients, and developing low BMD in endurance runners. Trial Registration: ClinicalTrials.gov Identifier: NCT01059968

Sassone, J, Muster, M, and Barrack, MT. Prevalence and predictors of higher-risk supplement use among National Collegiate Athletic Association Division I athletes. J Strength Cond Res 33(2): 443-450, 2019-This study aimed to identify the prevalence and predictors associated with the use of higher-risk dietary supplements, defined as supplements containing herbal ingredients, caffeine, or those classified for weight loss, muscle-building, or as a preworkout supplement, among 557 National Collegiate Athletic Association Division I male and female collegiate athletes. Although 252 (45.2%) athletes reported the use of a dietary supplement on ≥2 days per week over the past year, 46 (8.3%) athletes met criteria for higher-risk supplement use. Twenty (3.6%) athletes reported the use of herbal, 1 (0.2%) caffeinated, 5 (0.9%) weight loss, 28 (5.0%) preworkout, and 1 (0.2%) muscle-building supplements. Body mass index status (BMI ≥30 kg·m), sport-type (sports using the phosphocreatine energy system), and college year (≥4th year) were associated with the use of preworkout, muscle-building, or herbal supplements. A multiple regression analysis identified predictors of higher-risk supplement use including the number of dietary supplements used in the past year (odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.7-2.7, p < 0.001), the reported motivation of taking dietary supplements to gain muscle and lose body fat (OR = 3.5, 95% CI = 1.1-11.7, p = 0.04), and the motivation to increase athletic endurance (OR = 3.5, 95% CI = 4.0, 95% CI = 1.6-9.9, p < 0.005). These factors may be considered as a part of a screening process to evaluate athletes with an increased risk of higher-risk supplement use and potential consequences to health or eligibility status.

ObjectivesBone stress injuries (BSI) are common in runners of both sexes. The purpose of this study was to determine if a modified Female Athlete Triad Cumulative Risk Assessment tool would predict BSI in male distance runners.Methods156 male runners at two collegiate programmes were studied using mixed retrospective and prospective design for a total of 7 years. Point values were assigned using risk assessment categories including low energy availability, low body mass index (BMI), low bone mineral density (BMD) and prior BSI. The outcome was subsequent development of BSI. Statistical models used a mixed effects Poisson regression model with pResults42/156 runners (27%) sustained 61 BSIs over an average 1.9 years of follow-up. In the baseline risk factor model, each 1 point increase in prior BSI score was associated with a 57% increased risk for prospective BSI (p=0.0042) and each 1 point increase in cumulative risk score was associated with a 37% increase in prospective BSI risk (p=0.0079). In the longitudinal model, each 1 point increase in cumulative risk score was associated with a 27% increase in prospective BSI risk (p=0.05). BMI (rate ratio (RR)=1.91, p=0.11) and BMD (RR=1.58, p=0.19) risk scores were not associated with BSI.ConclusionA modified cumulative risk assessment tool may help identify male runners at elevated risk for BSI. Identifying risk factors may guide treatment and prevention strategies.

Early detection of the female athlete triad is essential for the long-term health of adolescent female athletes. The purpose of this study was to assess relationships between common anthropometric markers (ideal body weight [IBW] via the Hamwi formula, youth-percentile body mass index [BMI], adult BMI categories, and body fat percentage [BF%]) and triad components, (low energy availability [EA], measured by dietary restraint [DR], menstrual dysfunction [MD], low bone mineral density [BMD]). In the sample (n = 320) of adolescent female athletes (age 15.9± 1.2 y), Spearman’s rho correlations and multiple logistic regression analyses evaluated associations between anthropometric clinical cutoffs and triad components. All underweight categories for the anthropometric measures predicted greater likelihood of MD and low BMD. Athletes with an IBW ≤85% were nearly 4 times more likely to report MD (OR = 3.7, 95% CI [1.8, 7.9]) and had low BMD (OR = 4.1, 95% CI [1.2, 14.2]). Those in

Background: High school athletes participating in cross-country sports are at increased risk of overuse injuries. Little is known in younger athletes including those participating in running during middle school regarding prevalence of injuries or related risk factors. The objective of this study was to assess the frequency of sports-related injuries in middle school cross-country runners. Methods: This was a retrospective online survey study of middle school cross-country runners. Middle school cross-country coaches from middle school teams in the Boston area sent letters of invitation via email to the parents of their athletes to participate in an optional, anonymous online survey administered in REDCap. Participants received a $5 gift card for their time. The online survey included demographic information, weight, height, training variables, daily dietary patterns, and injury history. We conducted univariate and bivariate analyses while stratifying for sex. Results: A total of 101 subjects completed the survey, 47% (n=48) were female. Mean age was 12.5 years [SD 0.94], and 24% (n=24) were in sixth grade, 39% (n=39) in seventh grade, and 38 % (n=38) in 8th grade. The mean BMI for girls was 17.9 kg/m2 and for boys 18.24 kg/m2. The self-reported race/ethnicity was white in 72% (n=72), Asian in 22% (n=22), Latino in 5% (n=5), and black in 1% (n=1). Mean weekly mileage during the cross-country season was 15.2 miles [SD 7.6]. Of female subjects, 17% (n=8) reported that they were diagnosed with a bone stress injury (BSI) due to running, compared to 2% (n=1) of male subjects, p=0.009. The injured bones in females included the tibia (n=1), fibula (n=1), navicular (n=1) and metatarsal bones (n=6). The injured bone in the male was a sacral fracture. Compared to those without injury, runners with BSIs did not have observed differences in calcium or vitamin D intake; no differences were observed related to ball sport or other forms of strengthening exercises. A total of 63 non-fracture injuries occurred from running, with females (18%) more likely to have sprained ankles than males (6%, p=0.47). Conclusions/Significance: Running-related injuries are relatively common in middle school cross-country runners. In middle school, female runners are more likely to sustain running related BSIs than male runners. Efforts to prevent overuse stress injuries in middle school runners should be considered. Table. Demographic and injury history of middle school runners N=101 All (n=101) Girls (n=48) Boys (n=53) P value Age (years) 12.45 [0.94] 12.41 [0.81] 12.49 [1.05] 0.66 Grade6th 7th 8th 24% (24)39% (39)38% (38) 22% (11)41% (20)37% (18) 25% (13)37% (19)39% (20) 0.73 Weight (kg) 44.3 [8.08] 42.0 [7.022] 46.4 [8.19] 0.006 Height (cm) 155 [18.4] 150.9 [23.3] 160 [11.81] 0.021 BMI (kg/m2) 18.09 [2.99] 17.94 [3.30] 18.24 [2.69] 0.62 Race/ethnicityWhiteLatinoBlackAsian/Pacific IslanderOther 72% (72)5% (5)1% (1)22% (22)1% (1) 71% (34)8% (4)2% (1)19% (9)0%(0) 77% (41)3% (1)0% (0)25% (13)2% (1) 0.34 Absences from training last year due to injuryNoneOnce or twice3-4 times5 or moreDidn’t run last year 52% (53)35% (36)8% (8)2% (2)3% (3) 47% (23)39% (19)8% (4)2% (1)4% (2) 57% (30)32% (17)8% (4)2% (1)2% (1) 0.88 Diagnosed with a bone stress injury by a doctor 11% (11) 19% (9) 4% (2) 0.016 Diagnosed with a bone stress injury by a doctor due to running 9% (9) 17% (8) 2% (1) 0.0092 Injured boneTibiaFibulaMetatarsalSacrum 1*2*6 (1 female had both tibia/fibula fracture) 0001 InjuriesTotal injuriesAchilles tendonitisShin splintsRunner’s kneeIT band syndromeSprained ankleHamstring strainOsgood-Schlatter DiseaseSever diseaseOther tendon/bone/joint injuryPlantar fasciitis (63)8% (8)5% (7)13% (14)1% (1)12% (12)4% (4)4% (4)8% (8)5% (5) 3% (3) (39)8% (4)6% (3)20% (10)0% (0)18% (9)6% (3)6% (3)4% (2)6% (3) 4% (2) (25)8% (4)4% (2)8% (4)3% (1)6% (3)2% (1)2%(1)11% (6)4% (2) 2% (1) 0.910.580.0590.300.0470.270.270.170.58 0.51 *Some subjects had more than one injury.

A cross-sectional study of first-year college students was conducted to identify the prevalence and predictors of disordered eating (DE).College freshmen students, aged 18 years, (n = 106) completed the Eating Disorder Examination Questionnaire (EDE-Q) and a supplemental survey. A subset of the sample (n = 77) underwent measurements of height, weight, and body composition. DE was defined as an elevated (3) weight, shape, eating concern, or dietary restraint EDE-Q subscale score.The sample, consisting of 56.6%, 15.1%, 11.3%, and 11.3% Latino/a, Asian, African American, and Caucasian students, respectively (37% male), reported a 31.1% prevalence of DE. The current desire to lose weight was the strongest predictor of DE (odds ratio = 15.3; 95% confidence interval = 2.8, 82.5). Other variables linked to DE or elevated EDE-Q subscale scores included body mass index (BMI) 25.0 kg/mThis study adds to the current body of literature on DE by providing a diverse sample and potentially novel predictors and risk factors for DE.

Background Limited research has evaluated risk factors for low bone mineral density (BMD) in male adolescent athletes. Aims/objectives To evaluate predictors of low BMD (defined as BMD Z-score Methods Male adolescent athletes completed a survey characterising sports participation, nutrition, stress fracture history, dual energy X-ray absorptiometry (DXA)-measured BMD and body composition. Independent t-tests and analysis of covariance (ANCOVA) evaluated group differences; logistic regression evaluated low BMD risk factors. Results Runners (n=51) exhibited a lower body weight (p=0.02), body mass index (BMI) (kg/m2) (p=0.02), per cent expected weight (p=0.02) and spine BMD Z-score (p=0.002) compared with non-runners (n=18). Single risk factors of low BMD included 30 in the past year (OR=6.4, 95% CI 1.5 to 27.1). The strongest two-variable and three-variable risk factors included weekly mileage >30+ stress fracture history (OR=17.3, 95% CI 1.6 to 185.6) and weekly mileage >30+ 30, stress fracture history and Conclusions Male adolescent runners exhibited lower body weight, BMI and spine BMD Z-score values. The risk of low BMD displayed a graded relationship with increasing risk factors, highlighting the importance of using methods to optimise bone mass in this population.

The number of women participating in sports has increased dramatically in the past few decades. This rise in sports participation promotes numerous mental and physical benefits to the female athlete. However, clinical experience and research reports provide evidence of a health sequela, the “Female Athlete Triad,” developing as a result of inadequate dietary intake relative to exercise expenditure among a subset of athletes. The Female Athlete Triad (Triad) is an interrelated disorder of low energy availability, menstrual dysfunction, and reduced bone mineral density, and has been studied in various populations of athletic girls and women. In addition, current evidence suggests that athletes with Triad can experience other detrimental effects, including musculoskeletal, cardiovascular, gastrointestinal, renal, and neuropsychiatric symptoms. Female athletes participating in sports emphasizing leanness are at increased risk of developing the Triad. Factors that may account for this increased risk include an increased pressure to meet specific weight or body shape requirements of sport, the perceived benefit of a low body weight or thin frame in optimizing performance, and an increased susceptibility to sociocultural demands. These factors can lead to harmful dieting and subsequent energy deficit with likely health repercussions. Alternatively, some leanness sport athletes, such as those in endurance sports, may also develop an energy deficit inadvertently as a result of a high training volume and lack of awareness of their energy and nutritional needs. The specific risk biotypes considered in this chapter include endurance sports (e.g., runners, triathletes, cyclists, and swimmers), aesthetic sports (e.g., figure skating and gymnastics), weight-class sports (e.g., lightweight rowing and wrestling), and others. The involvement of a multidisciplinary team including sport medicine physicians, athletic trainers, dietitians, sports psychologists, among others, is required for the treatment of the Triad. The management comprises non-pharmacological and pharmacological approaches in some cases. However, the most effective way to avoid long-term consequences is early detection and prevention of this condition, especially in higher risk populations.

Background:Functional hypothalamic amenorrhea is common among female athletes and may be difficult to treat. Restoration of menses (ROM) is crucial to prevent deleterious effects to skeletal and reproductive health.Objectives:To determine the natural history of menstrual disturbances in female college athletes managed with nonpharmacologic therapies including increased dietary intake and/or decreased exercise expenditure and to identify factors associated with ROM.Study Design:A 5-yr retrospective study of college athletes at a major Division I university.Methods:373 female athletes’ charts were reviewed. For athletes with menstrual disturbances, morphometric variables were noted. Months to ROM were recorded for each athlete.Results:Fifty-one female athletes (19.7%) had menstrual disturbances (14.7% oligomenorrheic, 5.0% amenorrheic). In all, 17.6% of oligo-/amenorrheic athletes experienced ROM with nonpharmacologic therapy. Mean time to ROM among all athletes with menstrual disturbances was 15.6 ± 2.6 mo. Total absolute (5.3 ± 1.1 kg vs. 1.3 ± 1.1 kg, p < .05) and percentage (9.3% ± 1.9% vs. 2.3% ± 1.9%, p < .05) weight gain and increase in body-mass index (BMI; 1.9 ± 0.4 kg/m2 vs. 0.5 ± 0.4 kg/m2, p < .05) emerged as the primary differentiating characteristics between athletes with ROM and those without ROM. Percent weight gain was identified as a significant positive predictor of ROM, OR (95% CI) = 1.25 (1.01, 1.56), p < .05.Conclusions:Nonpharmacologic intervention in college athletes with menstrual disturbances can restore regular menstrual cycles, although ROM may take more than 1 yr. Weight gain or an increase in BMI may be important predictors of ROM.

This case demonstrates the potential serious consequences of the female athlete triad and its effects on bone. Displaced femoral neck stress fractures cause significant morbidity, and this case highlights the preventable nature of this injury. The treatment was focused on improving low energy availability, and, although challenging, improvements were made. This injury could have been prevented if the signs and symptoms of her injury had been addressed and there had been better knowledge of her risk factors. This case highlights the need for further education in the sports and health communities.

Endurance runners with low bone mass during adolescence may risk attaining a low peak bone mineral density (BMD) in adulthood. Alternatively, they may mature late and undergo delayed bone mineral accumulation. Purpose: The purpose of this study was to evaluate 40 adolescent runners (aged 15.9 ± 0.2 yr) at two time points, approximately 3 yr apart, to assess bone mass status and identify variables associated with bone mass change. Methods: Follow-up measures included a questionnaire to assess menstrual status, training, and sports participation history, height and weight, and a dual-energy x-ray absorptiometry scan to assess total body, total hip, and lumbar spine BMD, bone mineral content (BMC), BMD z-score, and body composition. We used -1 and -2 BMD z-score cutoffs to categorize runners with low bone mass. Results: Eighty-seven percent of girls with low BMD at baseline had low BMD at the follow-up. Girls with low compared with normal baseline BMD had lower follow-up adjusted total body (2220.4 ± 65.8 vs 2793.1 ± 68.2 g, P < 0.001), total hip (27.0 ± 1 vs 33.9 ± 1.0 g, P < 0.05), and lumbar spine (47.8 ± 2.0 vs 66.3 ± 2.2 g, P < 0.001) BMC values. Variables related to 3-yr training volume, menstrual function, age, developmental stage, and change in body mass explained 29%-54% of the variability in BMC change. Conclusions: The majority of adolescent runners with low BMD at baseline had low BMD after a 3-yr follow-up. Our observations suggest that "catch-up" accrual may be difficult and, thus, emphasize the importance of gaining adequate bone mineral during the early adolescent years.

Sports participation provides many health benefits to young athletes of both sexes. However, a subset of male athletes may suffer from unrecognised low bone density and impaired skeletal health, predisposing them to an increased risk of fracture. The effects of delayed diagnosis and inappropriate treatment of low bone density among male athletes may have severe consequences in future longevity in sport as well as long-term bone health. It has been well described that low energy availability alters the neuroendocrine axis, resulting in menstrual dysfunction, low bone mineral density (BMD) and increased risk for bone stress injury (BSI) in female athletes.1 ,2 However, male athletes may also experience an analogous process that parallels the female athlete triad (Triad).3 As childhood and adolescence represent a critical time for accruing peak bone mass, identifying modifiable risk factors for impaired skeletal health is important to ensure the long-term health in athletes of both sexes. Similar to female athletes,4 there appear to be cumulative risk factors for low BMD (Z-scores

Background: Female adolescent runners have an elevated prevalence of low bone mass for age—an outcome that may be partially due to inadequate energy intake. Objective: The objective was to evaluate diet, menstrual history, serum hormone concentrations, and bone mass in female adolescent runners with normal or abnormal bone turnover. Design: Thirty-nine cross-country runners (age: 15.7 6 0.2 y) participated in the study, which included a 7-d dietary assessment with the use of a food record and daily 24-h dietary recalls; serum measures of insulin-like growth factor I, estradiol, leptin, parathyroid hormone, progesterone, triiodothyronine, 25-hydroxycholecalciferol, bone-specific alkaline phosphatase (BAP), and cross-linked Ctelopeptides of type I collagen (CTX); an evaluation of height, weight, bone mass, and body composition with the use of dualenergy X-ray absorptiometry; and a questionnaire to assess menses and sports participation. Age- and sex-specific BAP and CTX concentrations of at least the 97th percentile and no greater than the third percentile, respectively, were considered abnormal. Results: All abnormal BAP and CTX concentrations fell within the elevated (! 97%) range. Runners with an elevated bone turnover (EBT) (n = 13) had a lower body mass, fewer menstrual cycles in the past year, lower estradiol and 25-hydroxycholecalciferol concentrations, and a higher prevalence of body mass index ,10% for age, vitamin D insufficiency, amenorrhea, and low bone mass. Girls with EBT consumed less than the recommended amounts of energy and had a higher prevalence of consuming ,1300 mg Ca than did those with normal bone turnover. Conclusions: Runners with EBT had a profile consistent with energy deficiency. Nutritional support to increase energy, calcium intake, and 25-hydroxycholecalciferol concentrations may improve bone mineral accrual in young runners with EBT. This trial was registered at clinicaltrials.gov as NCT01059968. Am J Clin Nutr 2010;92:652‐9.

During adolescence, skeletal integrity of girls is largely dependent on menstrual function and impact exercise, yet currently there is limited research regarding the interaction between menstrual status and type of mechanical loading associated with various high school sports. Our purpose was to examine associations of menstrual status, type of mechanical loading, and bone mineral density (BMD) in female high school athletes participating in high/odd impact or repetitive/non-impact sport. Participants were 161 female high school athletes (15.7+/-1.3 years; 165.3+/-6.9 cm; 59.4+/-8.7 kg) representing high/odd impact (n=93, including soccer, softball, volleyball, tennis, lacrosse, and track sprinters and jumpers), or repetitive/non-impact sports (n=68, including swimmers, cross-country and track distance runners who participated in events>or=800 m). Areal BMD was measured by DXA at the spine (L1-L4), proximal femur, and total body. Menstrual status was determined by self-report. Athletes with primary, secondary or oligomenorrhea were combined into a single group (oligo/amenorrheic) and compared to eumenorrheic athletes. Analysis of covariance (ANCOVA) with Bonferroni post hoc comparisons adjusted for age, BMI, and gynecological age were used to compare BMD of athletes in combined mechanical loading and menstrual status groups. We found significantly greater total hip (p=0.04) and trochanter (p=0.02) BMD (g cm(-2)) among eumenorrheic high/odd impact compared to eumenorrheic repetitive/non-impact athletes, and greater spine (p=0.01) and trochanter (p=0.04) BMD among high/odd impact eumenorrheic athletes compared to repetitive/non-impact oligo/amenorrheic athletes. Chi-squared analysis of BMD Z-scores adjusted for gynecological age showed a significantly greater percentage of repetitive/non-impact athletes (33.9%) compared to high/odd impact athletes (11.8%) with low spine BMD for their age (BMD Z-score

Participation in sports offers many health benefits to athletes of both sexes. However, subsets of both female and male athletes are at increased risk of impaired bone health and bone stress injuries. The Female Athlete Triad (Triad) is defined as the interrelationship of low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density. The Triad may result in health consequences, including bone stress injuries. Our review presents evidence that an analogous process may occur in male athletes. Our review of the available literature indicates that a subset of male athletes may experience adverse health issues that parallel those associated with the Triad, including low energy availability (with or without disordered eating), hypogonadotropic hypogonadism, and low bone mineral density. Consequently, male athletes may be predisposed to developing bone stress injuries, and these injuries can be the first presenting feature of associated Triad conditions. We discuss the evidence for impaired nutrition, hormonal dysfunction, and low bone mineral density in a subset of male athletes, and how these health issues may parallel those of the Triad. With further research into the mechanisms and outcomes of these health concerns in active and athletic men, evidence-based guidelines can be developed that result in best practice.

Serum iron levels have been shown to decline both with fever and with strenuous exercise, leading to the supposition that the decrease might be the result of a rise in core body temperature. To evaluate this hypothesis, the serum iron response to an exercise-induced 1.5 degrees C rise in core body temperature was measured. To increase core temperature, five females and two males exercised in an environmental chamber heated to 41 degrees C with a relative humidity of 40%. Blood samples were taken before exercise and immediately after body temperature increased approximately 1.5 degrees C. Blood was also collected 1 h, 6 h, and 24 h postexercise. Results showed that the core body temperature significantly increased (p